To: The Forbes Editor
Re: “Fed Is Best Foundation Says WHO Breastfeeding Guidelines Fail to Meet Human Rights Standards” (October 19, 2017)
In Kavin Senapathy’s opinion article, the suggestion that the 2017 revised WHO Baby Friendly Hospital Initiative (BFHI) guidelines place newborns at risk of starvation or severe complications is not supported by the evidence of decades of research in the area of breastfeeding and human milk. We are deeply concerned because it could lead to serious misunderstandings for expecting parents and the general population.
Breastfeeding is one of the most feasible, effective and low-cost preventive health interventions that has consistently been associated with substantial short- and long-term health benefits for children and mothers, including both developmental and cognitive outcomes (Britto et al., 2017; Rollins et al., 2016; Victora et al., 2016). Based on this evidence, we believe that breastfeeding adequately contributes to the well-being of infants.
As stated in the article, infant satiety is a human right (Kent, 2006; UN, 2016). We agree with the notion that we must acknowledge the existence of the problem of insufficient breastmilk. However, the article fails to consider that this problem, which is manifested as an inadequate supply of breastmilk needed to properly feed one's baby (Neifert, 2001; Wilson-Clay & Hoover, 2013), is most often characterized by a phenomenon known as perceived insufficient milk (Safon et al., 2017; Segura-Millán et al., 1994). Also known as insufficient milk syndrome, in the vast majority of cases it is the result of widespread lack of access to both prenatal and postnatal optimal breastfeeding support and lactation management rather than primary biological reasons (Gussler & Briesemeister, 1980; Tully & Dewey, 1985). The BFHI provides hospitals and maternity facilities with evidence-based guidelines so they can effectively manage and support all breastfeeding women and address such potential issues as this; in fact, a recent review of BFHI implementation globally found that adherence to the Ten Steps does indeed increase short, medium and long-term breastfeeding outcomes (Pérez-Escamilla et al., 2016).
This type of comprehensive breastfeeding support is a well-established intervention for improving breastfeeding outcomes, which ultimately improves the health of mothers and children. Breastfeeding support extends beyond educating mothers about the practice of breastfeeding and the importance of maternal and infant health, it can help dispel misunderstandings about best breastfeeding practices (McFadden et al., 2017; Safon et al., 2017; Segura-Millán et al., 1994; Tully & Dewey 1985). Support provided through initiatives like the BFHI provides individualized care to help mothers manage breastfeeding problems by specialized and well-trained staff (BFHI 2009 step 2 and 2017 step 9 and 3). Breastfeeding support helps women with breastmilk expression (BFHI 2009 steps 2, 3, 5 and 2017 steps 1, 3, 9) and knowing when to breastfeed (i.e., on-demand feeding; BFHI 2009 step 8 and 2017 step 3). It also provides education on evidence-based infant feeding practices, which includes initiating breastfeeding within the first hour after birth, breastfeeding exclusively for the first six months of life (BFHI 2009 steps 4, 6 and 2017 steps 2, 4) and continuing breastfeeding while introducing complementary feeding up until the first two years of life (WHO, 2016). Furthermore, the BFHI includes staff training that provides hands-on support and a referral system to both mothers and their families about identifying newborn hunger (i.e., identifying infant crying as a sign of hunger versus crying for another reason, which are many (Segura-Millán et al., 1994) (BFHI 2009 steps 5, 10 and 2017 steps 3, 6; Hackett et al., 2015). If BFHI is implemented and monitored well (BFHI 2017 step 10), this training should prevent starvation, as it involves the provision of best practices of care and support in the management of breastfeeding difficulties that could theoretically lead to infant hunger.
Overall, an extensive review of the literature was warranted but not employed in writing this opinion piece. We need to provide mothers with high-quality, unbiased and uncompromised breastfeeding support both during and after pregnancy. The health of the mothers and babies of the world depends on it. The ability of women to breastfed has been strongly protected through millions of years of evolution (otherwise the human species would have not survived) and currently it is estimated that less than 5 percent of women cannot breastfeed for purely physiological reasons (Neifert et al., 1991). Of course, the few mothers who have biological challenges for breastfeeding such as an underdeveloped mammary gland deserve to be strongly protected and supported with their infant needs as well by qualified health providers.
BBF is an evidence-based program at the Yale School of Public Health that works with global leaders in health and nutrition to assess their countries' readiness to expand their breastfeeding protection, promotion and support activities.
References
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Gussler, J. D., & Briesemeister, L. H. (1980). The insufficient milk syndrome: A biocultural explanation. Medical Anthropology, 4(2), 145-174.
Hackett, K. M., Mukta, U. S., Jalal, C. S., & Sellen, D. W. (2015). Knowledge, attitudes and perceptions on infant and young child nutrition and feeding among adolescent girls and young mothers in rural Bangladesh. Maternal & Child nutrition, 11(2), 173-189.
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Safon, C., Keene, D., Guevara, W. J. U., Kiani, S., Herkert, D., Muñoz, E. E., & Pérez‐Escamilla, R. (2017). Determinants of perceived insufficient milk among new mothers in León, Nicaragua. Maternal & child nutrition, 13(3).
Segura-Millán, S., Dewey, K. G., & Perez-Escamilla, R. (1994). Factors associated with perceived insufficient milk in a low-income urban population in Mexico. The Journal of nutrition, 124(2), 202-212.
Tully, J., & Dewey, K. G. (1985). Private fears, global loss: A cross‐cultural study of the insufficient milk syndrome. Medical anthropology, 9(3), 225-243.
UN. United Nations. Joint statement by the UN Special Rapporteurs on the Right to Food, Right to Health, the Working Group on Discrimination against Women in law and in practice, and the Committee on the Rights of the Child in support of increased efforts to promote, support and protect breast-feeding. 2016. Available at: http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=20871&LangID=E#sthash.NbpPVEPz.dpuf.
Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-490.
Wilson-Clay B, Hoover K. The infant feeding Atlas: Machaca TX: LactNews press; 2013.
WHO (2016) Media centre: Infant and young child feeding. Available: http://www.who.int/mediacentre/factsheets/fs342/en/ [Accessed 15 April 2016].